Cervical Intraepithelial Neoplasm Speaker: Tseng Jen-Yu

Introduction Cervical cancer was the most common malignancy in both incidence and mortality among women prior to the 20th century Incidence fallen dramatically in developed nations due to implementation of population based screening, detection, and treatment programs for pre-invasive disease

Epidemiology and Risk Factor 500,000 cases of cervical cancer diagnosed 2nd leading cause of cancer death Risk factors Sexually transmitted disease Human papilloma virus Multiple sexual partners Intercourse at early age Poor personal hygine Immunocompromise Cigarette smoking

Pathophysiology Transformation zone Metaplasia Area where glandular epithelium undergoes squamous metaplasia Metaplasia Occurs during fetal development / adolescence / and first pregnancy Columnar cells replaced by squamous cells Cells undergoing metaplasia are vulnerable to carcinogens

Bethesda System LSIL HSIL ASCUS AGUS Low grade squamous epithelial lesion HSIL High grade squamous epithelial lesion ASCUS Atypical squamous cells of undetermined significance AGUS Atypical glandular cells of undetermined significance

Terminology and Definition CIN I Mild dysplasia ( lower 1/3 of epithelium ) CIN II Moderate dysplasia ( 2/3 of epithelium ) CIN III Severe dysplasia ( upper 1/3 of epithelium / CIS ) Dysplasia Disorder maturation / Nuclear hyperchromatism Increased N/C ratio / Pleomorphism / Mitosis

CIN I Disease Profile Self limited sexually transmitted HPV infection 60% regress spontaneously 30% persistent 10 ~ 15% progress to CIN II / III 1% progress to invasive cancer

Follow up without treatment Ablation ( cryotherapy / laser ) Excision ( LEEP / Knife conization ) Follow up without treatment Pregnant women Immunosuppressed women Adolescents

CIN II / III Disease Profile 43% untreated CIN II spontaneous regression 32% untreated CIN III spontanenous regression 35% CIN II will persist 56% CIN III will persist 22% CIN II progress to CIS or invasive cancer 14% CIN II progress to CIS or invasive cancer

Follow up without treatment Ablation ( cryotherapy / laser ) Excision ( LEEP / Knife conization ) Follow up without treatment Pregnant women Adolescents

ASCUS Represent reactive / reparative changes secondary to inflammation 5% of routine Pap smears Treatment Repeat Pap smear in 4 ~ 6 months Colposcopy if repeat Pap shows ASCUS

AGUS Suspected glandular lesion that can’t be classified as reactive or neoplastic Higher risk of neoplasia ( adenocarcinoma ) 0.5 ~2.5% of routine Pap smear Treatment Colposcopy Conization + ECC

Colposcopy Acetic acid coagulation of nuclear protein preventing light to pass through the epithelium Higher nuclear density and higher concentration of protein => white intensity increase

Schiller / Lugol’s Iodine Normal, mature squamous epithelium contains abundant glycogen Produce dark brown stain Abnormal epithelium contains relatively little or no glycogen Remain relative unstained

Cryotherapy Indication Criteria Cytology / Colposcopy / ECC => No microinvasion Lesion in ectocervix Criteria CIN I / II Small lesion Ectocervix ECC negative No endocervical gland involvement

Conization Indication Unsatisfactory colposcopy Evidence of premalignant or malignant glandular epithelium Microinvasion on biopsy / colposcopy / Pap smear HSIL ( CIN II / CIN III ) Uncertainty regarding presence of microinvsaion or invasion following direct biopsy for CIn Inconsistent Pap smear and colposcopy

Cold Knife Indication Lesion extend to endocervical canal and extent not possible to confirm Extent exceeds capability of LEEP ( 1.5 cm ) Cytology shows atypical glandular cells Colposcopy suggest glandular dysplasia or adenocarcinoma Abnormal endocervical curretage

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